Moderate sedation. Procedure 34. Background

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1 Procedure 34 Clinical PRIVILEGE WHITE PAPER Moderate sedation Background According to The Joint Commission and the American Society of Anesthesiologists (ASA), moderate sedation (sometimes referred to as conscious sedation) is a druginduced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Moderate sedation does not include minimal sedation (anxiolysis) or deep sedation. Moderate sedation is used to facilitate the successful performance of a procedure or treatment while providing the patient comfort from anxiety and/or pain. It is not expected to induce depths of sedation that impair the patient s ability to maintain airway function, and cardiovascular function is usually maintained. During moderate sedation, a physician or certified registered nurse anesthetist (CRNA) administers sedative and/ or analgesic medications to the patient, or a physician supervises a qualified provider (where state regulations or hospital policy require supervision). According to the American Association of Nurse Anesthetists (AANA), healthcare providers monitor a patient s heart rate, blood pressure, breathing, oxygen level, and alertness during and after the administration of moderate sedation. Practitioners should be able to recognize complications or undesired outcomes and respond appropriately. Side effects and unexpected outcomes of moderate sedation include a brief period of amnesia after the procedure, headache, hangoverlike symptoms, nausea and vomiting, or unpleasant memories of the surgery or treatment. The Joint Commission (formerly JCAHO) used to consider moderate sedation as a non-anesthesia procedure; however, its revised standards now treat sedation/anesthesia as a continuum (i.e., minimal sedation [anxiolysis], moderate sedation, deep sedation, general anesthesia). To comply with Joint Commission standards, organizations may have to update their sedation/anesthesia policies and revise their privileging criteria for practitioners who provide sedation/anesthesia care. The standards (PC PC ) for sedation and anesthesia care appear in the Comprehensive Accreditation Manual for Hospitals (CAMH) and are effective January 1, Additionally, regulations regarding sedation administration by RNs who have not trained in anesthesia vary from state to state. Check all state licensure, state nurse practice acts, and institutional policies before creating a policy for this procedure.

2 Involved specialties CRNAs, anesthesiologists, dentists, dental anesthesiologists, podiatrists, surgeons, and physicians in numerous specialties and subspecialties Positions of societies and academies ASA The ASA is an educational, research, and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient. According to the ASA, anesthesiologists are responsible for administering anesthesia to relieve pain and for managing vital life functions (e.g., breathing, heart rhythm, and blood pressure) during surgery. After surgery, they maintain the patient in a comfortable state during the recovery and are involved in the provision of critical care medicine in the ICU. Please see Clinical Privilege White Paper, Anesthesiology Practice area 125 for privileging guidelines for anesthesiologists. The ASA recognizes that non-anesthesiologists also administer sedation/analgesia, and as a result developed Practice Guidelines for Sedation and Analgesia by Non-anesthesiologists. The guidelines apply to procedures performed in a variety of settings and are designed to provide recommendations for credentialing of nonanesthesiologist clinicians to provide patients with the benefits of sedation/analgesia while minimizing the associated risks. The ASA addresses the following in its practice guidelines: Patient evaluation Pre-procedure preparation Monitoring Recording of monitored parameters Availability of an individual responsible for patient monitoring Training of personnel Availability of emergency equipment Use of supplemental oxygen Combinations of sedative-analgesic agents Titration of IV sedative-analgesic medications Anesthetic induction agents used for sedation/analgesia IV access Reversal agents Recovery care Special situations 2

3 The ASA also published, separate from its practice guidelines for practitioners, the Statement on Granting Privileges for Administration of Moderate Sedation to Practitioners Who Are Not Anesthesia Professionals. The statement is designed to help healthcare organizations develop a protocol for delineating clinical privileges to administer sedative and analgesic drugs for non-anesthesia professionals. The ASA defines an anesthesia professional as an anesthesiologist, CRNA, and anesthesiology assistant, and defines a non-anesthesiologist sedation practitioner as a licensed physician, dentist, or podiatrist who has not completed postgraduate training in anesthesiology but is specifically trained to personally administer or supervise the administration of moderate sedation. The society further defines a supervised sedation professional as a licensed RN, advanced practice nurse, or physician assistant who is trained to administer medications and monitor patients during moderate sedation under the direct supervision of a non-anesthesiologist sedation practitioner or an anesthesiologist. Non-anesthesiologist sedation practitioners The ASA states that only physicians, dentists, or podiatrists who are qualified by education, training, and licensure to administer moderate sedation should supervise the administration of moderate sedation. Non-anesthesiologist sedation practitioners may directly supervise patient monitoring and the administration of sedative and analgesic medications by a supervised sedation professional. Alternatively, they may personally perform these functions, with the condition that the individual monitoring the patient should be distinct from the individual performing the diagnostic or therapeutic procedure. The ASA states that the non-anesthesiologist sedation practitioner who supervises or personally administers medications for moderate sedation should have completed a formal training program in the safe administration of sedative and analgesic drugs used to establish a level of moderate sedation and the rescue of patients who exhibit adverse physiologic consequences of a deeper-than-intended level of sedation. This training may be part of a recently completed residency of fellowship training (e.g., within two years) or it may be a separate educational program. A knowledge-based test may be used to verify the practitioner s understanding of those concepts. 3

4 The non-anesthesiologist sedation practitioner should have a current, active, and unrestricted medical, osteopathic, dental, or podiatric license in the state, district, or territory of practice. The only exception would be practitioners employed by the federal government who may have a current active license in any U.S. state, district, or territory. The practitioner should also have a current, unrestricted Drug Enforcement Administration registration. To evaluate the performance of a practitioner who is a recent graduate (within two years), organizations should obtain letters of recommendation from directors of residency or fellowship training programs, which include moderate sedation as part of the curriculum. When granting initial privileges for moderate sedation practitioners who have been in practice since completion of their training, organizations may communicate with department heads or supervisors at the institution where the individual holds privileges to administer moderate sedation. Alternatively, the non-anesthesiologist sedation practitioner could be proctored or supervised by a physician, dentist, or podiatrist who is currently privileged to administer sedative and analgesic agents to provide moderate sedation. The facility should establish an appropriate number of procedures to be supervised. Supervised sedation professional According to the ASA, the supervised sedation professional who is granted privileges to administer sedative and analgesic drugs under the supervision of a non-anesthesiologist sedation practitioner or anesthesiologist and to monitor patients during moderate sedation can be an RN or a physician assistant. They may only administer sedative and analgesic medications on the order of an anesthesiologist or non-anesthesiologist sedation practitioner. They should have completed a formal training program in: The safe administration of sedative and analgesic drugs used to establish a level of moderate sedation Use of reversal agents for opioids and benzodiazepines Monitoring of patients physiologic parameters during sedation Recognition of abnormalities in monitored variables that require intervention by the non-anesthesiologist sedation practitioner or anesthesiologist The supervised sedation professional should have a current, active nursing license or physician assistant license or certification in the U.S. state, district, or territory of practice. The 4

5 only exception would be practitioners employed by the federal government who may have a current active license in any U.S. state, district, or territory. The ASA also publishes Recommended Scope of Practice of Nurse Anesthetists and Anesthesiologist Assistants. AANA The AANA is a professional association for CRNAs and student nurse anesthetists. CRNAs are advanced practice nurses who are the hands-on providers of approximately 32 million anesthetics in the United States each year. According to the AANA, CRNAs administer every type of anesthetic, work in every type of practice setting, and provide care for every type of surgery and procedure, from open heart to cataract to pain management. The practice of nurse anesthesia is a long-standing specialty within the profession of nursing. The AANA publishes privileging guidelines for CRNAs titled Guidelines for Core Clinical Privileges. The AANA also publishes detailed information regarding CRNA scope of practice in its Scope and Standards for Nurse Anesthesia Practice. In addition, the AANA publishes Considerations for Policy Guidelines for Registered Nurses Engaged in the Administration of Sedation and Analgesia. The AANA suggests these policy guidelines to promote safe care during sedation and analgesia and to address questions raised by RNs not trained in anesthesia involved in this care. The AANA suggests the following requirements for RNs not trained in anesthesia who engage in the delivery of sedation and analgesia: RN-administered sedation and analgesia is allowed by state law and institutional policy The healthcare facility has an educational/credentialing mechanism that includes a process for evaluating and documenting the individual s competency relating to the management of patients receiving sedation and analgesia Evaluation and documentation occurs on a periodic basis Further, the AANA suggests that RNs managing and monitoring the care of patients receiving sedation and analgesia be able to: Demonstrate the acquired knowledge of anatomy, physiology, pharmacology, cardiac arrhythmia recognition, and complications related to sedation and analgesia sedation and medications 5

6 Assess the total patient care requirements before and during the administration of sedation and analgesia, including the recovery phase Understand the principles of oxygen delivery, transport and uptake, respiratory physiology, as well as understand and use oxygen delivery devices Recognize potential complications of sedation and analgesia sedation for each type of agent being administered Possess the competency to assess, diagnose, and intervene in the event of complications and institute appropriate interventions in compliance with orders or institutional protocols Demonstrate competency, through advanced cardiac life support (ACLS) or pediatric cardiac life support, in airway management and resuscitation appropriate to the age of the patient Understand the legal ramifications of providing care and maintain appropriate liability insurance ASGE The American Society for Gastrointestinal Endoscopy (ASGE) members are clinicians trained to perform endoscopic procedures of the gastrointestinal track. The ASGE approved the ASA s Practice Guidelines for Sedation and Analgesia by Non-anesthesiologists, and the organization published its own practice guideline, Sedation and Anesthesia in GI Endoscopy. According to this document, most endoscopic procedures require the patient to be under moderate sedation. The ASGE sets forth the following guidelines for providers administering moderate sedation: Providers must understand the medicines used in endoscopic sedation and the skills necessary to diagnose and treat cardiopulmonary complications. During moderate sedation, the person assigned responsibility for patient assessment may also perform tasks that are interruptible and of short duration. Non-anesthesiology physicians and nurses may administer anesthesia as long as they have the proper training and credentialing in administration and rescue from pulmonary and cardiovascular complications. Providers administering sedation should have training and skills to rescue patients who reach a deeper level of sedation than originally intended. Thus, a physician targeting moderate sedation must be able to rescue a patient who is deeply sedated. 6

7 Providers should consider using an anesthesia specialist during emergency endoscopic procedures, complex endoscopic procedures, and for patients with a history of adverse reaction to sedation, inadequate response to moderate sedation, anticipated intolerance of standard sedatives (e.g., alcohol or substance abuse), and those at risk for sedation-related complications. SGNA ADA The Society of Gastroenterology Nurses and Associates (SGNA), a professional organization of nurses and associates who practice gastroenterology and endoscopy nursing, published the Statement on the Use of Sedation and Analgesia in the Gastrointestinal Endoscopy Setting. With regard to moderate sedation, the document states that gastroenterology nurses who are trained and experienced in endoscopy can: Administer and maintain moderate sedation by order of a physician Administer reversal agents prescribed by physicians Assess, diagnose, and intervene in the event of complications Monitor and assess the patient receiving moderate sedation throughout diagnostic and therapeutic endoscopic procedures Additionally, the SGNA says RNs monitoring the patient may assist with minor, interruptible tasks once the patient s level of sedation and vital signs have stabilized. However, for complex procedures or severe patient illness, a second nurse or associate is required to assist the physician. The American Dental Association (ADA) publishes a policy statement titled The Use of Sedation and General Anesthesia by Dentists. The statement addresses the use of general anesthesia and minimal, moderate, and deep sedation. According to the policy statement, training to achieve competency in moderate sedation techniques may be acquired at the predoctoral, postgraduate, graduate, or continuing education level. Dentists who want to use moderate sedation are expected to successfully complete formal training that is structured in accordance with the association s Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students. The ADA urges dental practitioners to regularly participate in continuing education in the areas of sedation and anesthesia. 7

8 The ADA publishes Guidelines for the Use of Sedation and General Anesthesia by Dentists. The guidelines were designed to help dentists deliver safe and effective sedation and anesthesia. Dentists who provide sedation and anesthesia in compliance with their state rules and/or regulations prior to adoption of this document are not subject to the following educational requirements regarding moderate sedation. To administer moderate sedation, the ADA states that a dentist must have successfully completed: 1. A comprehensive training program in moderate sedation that satisfies the requirements described in the Moderate Sedation section of the ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students at the time training was commenced Or 2. An advanced education program accredited by the ADA Commission on Dental Accreditation that affords comprehensive and appropriate training necessary to administer and manage moderate sedation commensurate with these guidelines And 3. A current certification in basic life support for healthcare providers and ACLS or an appropriate dental sedation/anesthesia emergency management course The ADA states that administration of moderate sedation by another qualified dentist or independently practicing qualified anesthesia healthcare provider requires the operating dentist and his or her clinical staff to maintain current certification in basic life support for healthcare providers. ACR The American College of Radiology is the principal organization for radiologists in the United States. Its membership includes radiologists, radiation oncologists, medical physicists, interventional radiologists, and nuclear medicine physicians. In 2005, the organization revised its ACR Practice Guideline for Adult Sedation/Analgesia, which includes information regarding moderate sedation. According to the ACR, the supervising physician should have the following qualifications: Sufficient knowledge of the pharmacology, indications, and contraindications for the use of sedative agents The ability to recognize and initiate treatment for adverse reactions, including the appropriateness of reversal agents 8

9 Appropriate continuing education in accordance with the ACR Practice Guideline for continuing medical education Ability to demonstrate the skills in basic life support and the knowledge and skills to intervene in the event of complications The physician caring for the patient in the imaging/interventional suite should meet the credentialing requirements of the facility The ACR Practice Guideline for Adult Sedation/Analgesia states that the healthcare provider responsible for monitoring the patient should: Be a physician, nurse, or other licensed healthcare provider authorized by the facility whose primary job is to monitor the patient Be certified according to the pathway appropriate to the profession Be trained and competent in basic resuscitation measures Be knowledgeable in the use, side effects, and complications of the sedative agent(s) and reversal agents to be administered Be knowledgeable and experienced in monitoring vital signs, using pulse oximetry, and using cardiac monitoring, including the recognition of cardiac arrythmias Meet the credentialing requirements of the facility Additionally, the ACR says that monitoring the patient should be the focus of this individual, and he or she should have minimal other duties during the procedure. The guidelines also recommend that a person qualified in ACLS be on-site. Positions of other interested parties Dean F. Smith, MD Phoenix According to Dean F. Smith, MD, of Valley Anesthesiology Consultants in Phoenix, hospitals are developing strict criteria for physicians in regard to privileging for moderate sedation. The move is in response to the 2001 Joint Commission standards, which included new definitions for general anesthesia and light, moderate, and deep sedation. The standards apply to all licensed independent practitioners (LIP), the definition of which varies from state to state, Smith says. In some states, CRNAs are not independent practitioners and are supervised by a physician. In other states, CRNAs are considered LIPs. Even in some states that recognize CRNAs as LIPs, hospitals within those states can establish standards 9

10 maintaining that an independent practitioner must be a physician. The variances have led many facilities to require ACLS or pediatric advanced life support (PALS) certification for anyone who administers anesthesia, says Smith. Anesthesiologists training prepares them to administer moderate sedation, Smith says. Specialists, such as gastroenterologists and pulmonologists, would receive training to administer moderate sedation during their fellowship. According to Smith, Joint Commission surveyors expect institutions to determine how practitioners will manage patients with potentially difficult airways or those who are more sensitive to suppression of spontaneous ventilation by the sedation. Most hospitals expect moderate sedation practitioners to be competent in the rescue of a patient. The Joint Commission doesn t specifically require practitioners to have ACLS certification, Smith says. But that s one option the institution may want to consider. If ACLS is not used, some alternative program or process to demonstrate competency is necessary. The most important thing from a patient safety standpoint is that practitioners who administer any sort of sedation need to demonstrate the ability to handle complications arising from movement to a deeper level of sedation, Smith adds. Anesthesiologists are trained to evaluate airways and evaluate patients who might be more prone to dangerous side effects of sedative medications. Additionally, the increase in obesity rates has made obstructive sleep apnea more common, Smith says. If a patient experiences sleep apnea while on the operating table, the practitioner needs to be able to respond appropriately. A challenge for practitioners is anticipating which patients may become compromised and how to respond, Smith says. It may just mean appropriate head positioning, such as tilting the head back or bringing the jaw forward. In some cases, placement of an artificial airway may be necessary. According to Smith, the need for moderate sedation has increased along with the increase in minimally invasive surgeries. Examples include cardiologists who implant pacemakers and electrophysiologists who perform radiofrequency ablation procedures. 10

11 Some of these procedures, if not unheard of in 2001, are certainly being done today with moderate sedation, says Smith. To become competent in moderate sedation, Smith says physicians should administer moderate sedation to 50 patients per year. If all 50 cases occurred in the same institution, there would be more meaningful data to examine. James R. Walker, CRNA, DNP Houston James R. Walker, CRNA, DNP, is president of the AANA ( ) and director of the graduate program in nurse anesthesia at Baylor College of Medicine in Houston, where he is an associate professor of anesthesiology and allied health sciences. To become a CRNA, candidates first earn a bachelor s degree, most often in nursing. From there, they complete a master s degree program that is months in length. The educational process includes didactic and clinical experience requirements defined by the Council on Accreditation of Nurse Anesthesia Educational Programs. Walker says that part of the educational process for a CRNA is to learn how to use similar drugs at different doses at different times to achieve a certain level of sedation. CRNAs learn these skills throughout their entire curriculum in the didactic and clinical phases of the program. Regardless of the intended depth of sedation, if the patient enters a deeper level of sedation, then the person who administers the sedation must be qualified to handle that, Walker says. The complications from anesthesia are going to be handled by the anesthesia provider. If surgical or procedural complications arise, then the anesthesia professional is going to consult a specialist in that area. CRNAs are licensed to administer moderate sedation all the way up to general anesthesia in every single state. Federal and state laws govern whether CRNAs practice under supervision. On December 11, 2009, the Centers for Medicare & Medicaid Services (CMS) issued revised Interpretive Guidelines for hospitals. CMS does not require physician supervision of minimal and moderate sedation services provided by CRNAs. Thus, physician supervision of topical or local anesthesia, minimal sedation, or moderate sedation/analgesia services (e.g., labor epidurals) provided by CRNAs is only required if mandated under applicable state law, such as in the nurse practice act or hospital licensing statute. 11

12 Walker refrains from providing the yearly number of cases that would show competence, stating that if a nurse anesthetist is administering general anesthesia, he or she is going to have the skills to administer lower levels of sedation. Walker adds that facilities should develop institutional policies for anesthesia and that anesthesia providers should understand and follow the policies. CMS On December 11, 2009 (updated February 5, 2010), CMS sent a letter to state survey agency directors regarding Revised Hospital Anesthesia Services Interpretive Guidelines. In this letter, CMS states that certain anesthesia services are subject to specific administration/supervision requirements. The regulations specify that anesthesia must only be administered by certain qualified anesthesia professionals and establish supervision requirements for nonphysician professionals. In the case of CRNAs, unless the CRNA is practicing in an optout state, he or she must be supervised when administering anesthesia. Local anesthetics and minimal and moderate sedation are not considered anesthesia; therefore, they are not subject to supervision requirements. The Joint Commission The Joint Commission standards for moderate and deep sedation and anesthesia apply when patients in any setting receive, for any purpose, by any route: General, spinal, or other major regional anesthesia Moderate or deep sedation (with or without analgesia) that, in the manner used, may be expected to result in the loss of protective reflexes The standards that appear in the 2010 CAMH are as follows: Standard PC The hospital plans operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia. EPs for this standard state that individuals administering moderate or deep sedation and anesthesia are qualified and have the credentials to manage and rescue patients at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally. A sufficient number of qualified staff must be present to evaluate the patient, provide the sedation and/or 12

13 anesthesia, help with the procedure, and monitor and recover the patient. An RN supervises the perioperative nursing care. For operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia, the hospital has: Equipment to monitor the patient s physiological status Equipment available to administer IV fluids and medications and blood and blood components Resuscitation equipment available Standard PC The hospital provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of deep sedation or anesthesia. Before operative or other high-risk procedures are initiated, or before moderate or deep sedation or anesthesia is administered, the hospital: Conducts a pre-sedation or pre-anesthesia patient assessment Assesses the patient s anticipated needs in order to plan for the post-procedure care Provides the patient with pre-procedural treatment and services, according to his or her plan for care Provides the patient with pre-procedural education, according to his or her plan for care Before administering moderate or deep sedation or anesthesia, an LIP plans or concurs with the plan for sedation or anesthesia. A pre-anesthesia evaluation is completed and documented by an individual qualified to administer anesthesia within 48 hours prior to surgery or a procedure requiring anesthesia services. The hospital reevaluates the patient immediately before administering moderate or deep sedation or anesthesia. Standard PC Standard PC The hospital monitors the patient during operative or other highrisk procedures and/or during the administration of moderate or deep sedation or anesthesia. During operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia, the patient s oxygenation, ventilation, and circulation are monitored continually. The hospital provides care to the patient after operative or other high-risk procedures and/or the administration of moderate or deep sedation or anesthesia. 13

14 EPs for this standard include: The hospital assesses the patient s physiological status immediately after and/or as the patient recovers. The hospital monitors the patient s physiological status, mental status, and pain level at a frequency and intensity consistent with the potential effect of the procedure and/ or the sedation or anesthesia administered. A qualified LIP discharges the patient from the recovery area or from the hospital. In the absence of a qualified LIP, patients are discharged according to criteria approved by clinical leaders. Patients who have received sedation or anesthesia as outpatients are discharged in the company of an individual who accepts responsibility for the patient. A post-anesthesia evaluation is completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery is completed in accordance with law and regulation and policies and procedures approved by the medical staff. CRC draft criteria Minimum threshold criteria for requesting core privileges to administer moderate sedation The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding this procedure. Basic education: MD, DO, CRNA, DDS, DMD, DPM Minimal formal training: Completion of an Accreditation Council for Graduate Medical Education (ACGME)/American Osteopathic Association (AOA) accredited residency training program in anesthesiology, a Council on Accreditation of Nurse Anesthesia Educational Programs accredited school of nursing program in anesthesia, or an ADA-accredited advanced or postgraduate training program in dental anesthesiology. Non-anesthesiologist practitioners should show that training in administering moderate sedation was part of their residency or specialty training program, or that they have completed a formal training program in moderate sedation. All practitioners must have current ACLS, PALS, or NRP certification. Required previous experience: Applicants must be able to demonstrate current competence and evidence of the administration of moderate sedation to at least 50 patients in the previous 12 months. 14

15 Additional consideration References Practitioners who administer moderate sedation should be certified in ACLS (or PALS or NALS for pediatric or neonatal providers). A letter of reference should come from the director of the applicant s anesthesiology residency, nurse anesthesia program, or moderate sedation training program. Alternatively, a letter of reference should come from the anesthesiologist or CRNA who is familiar with the applicant s performance of moderate sedation procedures at the institution where the applicant most recently practiced. Reappointment Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanism. Applicants must demonstrate that they have maintained competence by documenting that they have administered moderate sedation for at least 50 patients annually over the reappointment cycle based on the results of ongoing professional practice evaluation and outcomes. In addition, continuing medical education related to moderate sedation should be required. For more information For more information regarding this procedure, contact: American Association of Nurse Anesthetists 222 South Prospect Avenue Park Ridge, IL Telephone: 847/ Fax: 847/ Web site: American College of Radiology 1891 Preston White Drive Reston, VA Telephone: 703/ Web site: American Dental Association 211 East Chicago Avenue Chicago, IL Telephone: 312/ Web site: 15

16 American Society of Anesthesiologists 520 North Northwest Highway Park Ridge, IL Telephone: 847/ Fax: 847/ Web site: American Society for Gastrointestinal Endoscopy 1520 Kensington Road, Suite 202 Oak Brook, IL Telephone: 630/ Fax: 630/ Web site Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD Telephone: 877/ Web site: The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL Telephone: 630/ Fax: 630/ Web site: Society of Gastroenterology Nurses and Associates 401 North Michigan Avenue Chicago, IL Telephone: 800/ Fax: 312/ Web site: Valley Anesthesiology Consultants 1850 N. Central Avenue, Suite 1600 Phoenix, AZ Telephone: 602/ Fax: 602/ Web site: 16

17 Privilege request form Moderate sedation To be eligible to request clinical privileges to administer moderate sedation, an applicant must meet the following minimum threshold criteria: Basic education: MD, DO, CRNA, DDS, DMD, DPM Minimum formal training: Completion of an ACGME/AOA-accredited residency training program in anesthesiology, a Council on Accreditation of Nurse Anesthesia Educational Programs accredited school of nursing program in anesthesia, or an ADA-accredited advanced or postgraduate training program in dental anesthesiology. Non-anesthesiologist sedation practitioners should show that training in administering moderate sedation was part of their residency or specialty training program, or that they have completed a formal training program in moderate sedation. All practitioners must have current ACLS, PALS, or NRP certification. Required previous experience: Applicants must be able to demonstrate that they have administered moderate sedation for at least 50 patients in the previous 12 months. References: A letter of reference should come from the director of the applicant s anesthesiology residency, nurse anesthesia program, or moderate sedation training program. Alternatively, a letter of reference should come from the anesthesiologist or CRNA who is familiar with the applicant s performance of moderate sedation procedures at the institution where the applicant most recently practiced. Reappointment: Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanism. Applicants must demonstrate that they have maintained competence by documenting that they have administered moderate sedation for at least 50 patients annually over the reappointment cycle based on the results of ongoing professional practice evaluation and outcomes. In addition, continuing medical education related to moderate sedation should be required. I understand that by making this request, I am bound by the applicable bylaws or policies of the hospital, and hereby stipulate that I meet the minimum threshold criteria for this request. Physician s signature: Typed or printed name: Date: 17

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20 Editorial Advisory Board Clinical Privilege White Papers Associate Group Publisher: Erin Callahan, Associate Editor: Julie McCoy, William J. Carbone Chief Executive Officer American Board of Physician Specialties Atlanta, GA Darrell L. Cass, MD, FACS, FAAP Codirector, Center for Fetal Surgery Texas Children s Hospital Houston, TX Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, CA Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, AZ Bruce Lindsay, MD Professor of Medicine Director, Cardiac Electrophysiology Washington University School of Medicine St. Louis, MO Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Marblehead, MA Richard A. Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Marblehead, MA The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2010 HCPro, Inc., Marblehead, MA